Bacterial Prostatitis

REVIEW CURRENT OPINION Bacterial prostatitis Bradley C. Gill a,b and Daniel A. Shoskesa,b Purpose of review The review provides the infectious disease community with a urologic perspective on bacterial prostatitis. Specifically, the article briefly reviews the categorization of prostatitis by type and provides a distillation of new findings published on bacterial prostatitis over the past year. It also highlights key points from the established literature. Recent findings Cross-sectional prostate imaging is becoming more common and may lead to more incidental diagnoses of acute bacterial prostatitis. As drug resistance remains problematic in this condition, the reemergence of older antibiotics such as fosfomycin, has proven beneficial. With regard to chronic bacterial prostatitis, no clear clinical risk factors emerged in a large epidemiological study. However, bacterial biofilm formation has been associated with more severe cases. Surgery has a limited role in bacterial prostatitis and should be reserved for draining of a prostatic abscess or the removal of infected prostatic stones. Summary Prostatitis remains a common and bothersome clinical condition. Antibiotic therapy remains the basis of treatment for both acute and chronic bacterial prostatitis. Further research into improving prostatitis treatment is indicated. Keywords acute bacterial prostatitis, bacterial prostatitis, category I prostatitis, category II prostatitis, chronic bacterial prostatitis, male pelvic pain INTRODUCTION and August 2015 were identified among the first Prostatitis is a bothersome condition but carries 600 search results. The titles of English language potential for serious morbidity from sepsis, abscess, articles were examined and those pertaining to non- or fistula if insufficiently managed. Nearly one in six bacterial prostatitis, chronic pelvic pain, and animal men report a history of prostatitis, resulting in over or basic science models were excluded. After this, a $84 million in annual medical expenditure [1,2]. total of 38 articles related to acute and chronic Prostatitis exhibits a bimodal peak of incidence, bacterial prostatitis were reviewed. with men between 20 and 40 years of age or older than 60 years afflicted most commonly [3]. The Prostatitis categorization scheme reasons for this distribution or potential for con- The National Institutes of Health consensus classi- founding by sexually transmitted infections are fication of prostatitis (Table 1) divides the condition unknown. In over 90% of men with fever and uri- into four categories based upon clinical presentation nary symptoms, prostatitis is the underlying con- [7]. These include acute (category I) and chronic dition in the absence of pyelonephritis symptoms (category II) bacterial prostatitis, as well as chronic [4]. With that, prostatitis accounts for nearly 8% of prostatitis/pelvic pain syndrome (category III) and urologist visits [5]. Overall, prostatitis remains a common condition and research to improve its a management would be beneficial. Department of Urology, Glickman Urological and Kidney Institute and bLerner College of Medicine, Education Institute, Cleveland Clinic, This review provides a distillation of notable Cleveland, Ohio, USA additions to the literature on prostatitis over the Correspondence to Daniel A. Shoskes, MD, Department of Urology, past year. It builds upon the journal’s February 2014 Glickman Urological and Kidney Institute, Cleveland Clinic, Mail Stop & review [6 ]. Additionally, it provides a brief overview Q10–1, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Tel: +1 216 of prostatitis categorization. To complete this manu- 445 4757; fax: +1 216 444 0390; e-mail: [email protected] script, a PubMed query for ‘prostatitis’ was con- Curr Opin Infect Dis 2016, 29:86–91 ducted and articles dated between January 2014 DOI:10.1097/QCO.0000000000000222 www.co-infectiousdiseases.com Volume 29 Number 1 February 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Bacterial prostatitis Gill and Shoskes (dysuria, urinary frequency, and urinary urgency), KEY POINTS and focal symptoms (pelvic or perineal pressure) Tailoring antibiotic treatment to culture-proven bacterial suggestive of prostatic involvement. Obstructive sensitivity is essential. urinary symptoms (weak stream, dribbling, and hesitancy) may also present, with urinary retention Any chosen antibiotic must penetrate the prostate and possible. Commonly, an intervention such as trans- reach therapeutic levels. rectal ultrasound-guided prostate biopsy may Antibiotic resistance is increasingly problematic. precede presentation. A sexual history may indicate the risk of a sexually transmitted infection. The indications for surgery in managing prostatitis Rectal examination almost always shows a ten- remain limited and very specific. der prostate. However, caution is warranted during digital rectal examination, as aggressive prostate palpation can release bacteria and inflammatory asymptomatic inflammatory prostatitis (category cytokines triggering an abrupt clinical decompensa- IV). To date, no data support the role of ‘hidden’ tion, thus contraindicating prostatic massage. infection or atypical organisms in category III or IV Serum laboratory assessment in CIP generally prostatitis. As such, there is no role for antibiotic reveals leukocytosis. During infection, prostate- therapy in these conditions, despite many patients specific antigen is invariably elevated and has no strongly believing a true infection exists and seeking diagnostic value for prostate cancer. Urinalysis and out multiple practitioners to diagnose one. urine culture are essential and blood cultures are indicated for a clinical suspicion of sepsis. All men should have a postvoid residual urine volume CATEGORY I PROSTATITIS: ACUTE measurement, as urinary retention may not be evi- BACTERIAL PROSTATITIS dent. Imaging with computed tomography (CT) Acute bacterial prostatitis or National Institutes of scan or ultrasound may reveal an enlarged and Health category I prostatitis (CIP) is defined as an inflamed heterogeneously appearing prostate, but acute urinary tract infection (UTI) with prostatic is not necessary unless concern for prostatic abscess involvement. Patients are usually febrile and may exists. present with urinary retention. Infection results from bacteria ascending the urethra, reflux of con- taminated urine into the prostatic ducts, direct Treatment introduction of bacteria during transrectal biopsy Successful treatment of CIP rests upon completion or urethral instrumentation, or hematogenous seed- of a sufficient course of appropriate antibiotic. The ing. Causative organisms include Escherichia coli in agent used must have demonstrated sensitivity most (65–80%) cases with Pseudomonas aeruginosa, against the infecting organism and also reach thera- Proteus mirabilis, Klebsiella spp., Serrita, and Enter- peutic levels in the prostate. During acute infection obacter spp. comprising the remainder [8–10]. With with prostatic inflammation, most antibiotics do impaired immunity, other microorganisms like penetrate the prostate (except nitrofurantoin) fungi (Cryptococcus spp. or Histoplasma spp.) and [11]. Without evidence of systemic disease or uri- Gram-positive (skin flora) bacteria, as well as Myco- nary retention, an oral antibiotic for 2–4 weeks is bacterium tuberculosis may be implicated. generally sufficient. Typical agents include a fluoroquinolone or trimethoprim-sulfamethoxazole, Diagnosis with the quinolones reaching 3–4 times higher Men typically present with systemic symptoms intraprostatic concentrations than beta-lactam anti- (malaise, fevers, chills, and sweats), evidence of UTI biotics [10]. Repeat urine culture during therapy to assess for bacterial eradication is necessary, if clinical Table 1. National Institutes of Health consensus definition improvement is not seen, however, all cases of CIP and classification of prostatitis should have a confirmatory urine culture about 1 week following antibiotic completion to ensure National Institutes of Health consensus definition and bacteriologic cure. classification of prostatitis The acutely ill patient warranting hospitaliz- Category I Acute bacterial prostatitis ation for prostatitis will present a clinical picture Category II Chronic bacterial prostatitis of sepsis or a systemic inflammatory response syn- Category III Chronic prostatitis/chronic pelvic pain syndrome drome. Urinary tract decompression is often Category IV Asymptomatic inflammatory prostatitis required for urinary retention with grossly infected urine via a short-term indwelling urethral catheter, 0951-7375 Copyright ß 2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-infectiousdiseases.com 87 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Urinary tract infections clean intermittent urethral catheterization, or a Urologic procedures may incite UTIs and pros- suprapubic catheter. Parenteral antibiotic therapy tatitis. A case report detailed a case of Salmonella is indicated until clinical stabilization is achieved, typhimurium prostatitis in a spinal cord injury with the chosen regimen guided by local anti- patient performing clean intermittent urethral biogram results. Typical treatment consists of catheterization and discussed the role of perineal empiric broad coverage with a fluoroquinolone colonization and bacterial seeding in such a setting and aminoglycoside, possibly in combination with [19]. A comparison of the clinical details

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